Proper 12 lead EKG electrode placement

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Permalink Reply by Marnie Toothaker on February 26, 2009 at 12:02am

When I am doing 12 lead EKG's in the hospital I also put the extremity electrodes/leads on the extremities.
When I do them in the field in the back of an ambulance, I place them on the torso. This cuts down on the amount of artifact in the tracing.

Permalink Reply by TheCannulator on February 26, 2009 at 1:06am

Einthoven's triangle is essentially Einthoven's triangle.

So long as you have adequate distance between electrodes to truly represent each limb lead then good. Upper limbs is adequate for LA/RA for example to reduce artifact.

Perhaps Tom could comment as he's the prehospital 12 lead blogger!

You shouldn't get artifact with good skin pre-most do nothing- and a stable recording platform. You shouldn't be doing 12 leads in a moving vehicle for example and expecting a good trace.

Permalink Reply by blair4630 on February 26, 2009 at 4:52am

Personally I keep the limb lead on the torso, for the same reason mentioned, less movement, less artifact. On the flip side, in a hospital, alot of times you can have the controlled enviroment that if they are able to lie perfectly still it shouldn't be a problem either way.

Permalink Reply by Tom Bouthillet on February 26, 2009 at 9:48am

You're too kind, Cannulator!

I have some general comments about capturing a 12 lead ECG with good data quality here. I also mention it here because poor data quality can mess with the computerized interpretive algorithm.

In my opinion, limb lead electrodes should be placed on the extremities when possible. I have had good success placing the white and black electrodes in the center of the deltoids, which usually isn't too hairy and leaves plenty of room for the blood pressure cuff.

I do this for all patients whether it's a 3-lead, 6-lead, or 12-lead ECG. Sometimes you decide to upgrade a patient to a 12-lead and all you have to do is place the precordials.

For the red and green electrodes, I prefer the muscle mass of the quads for a clean tracing. Sometimes, when it's a female patient with long pants and stockings, it's not worth it, and I will go for a spot on the lower abdomen, but I don't prefer it.

Placing the limb lead electrodes on the body reduces artifact for patients in the hospital who may be walking around and/or brushing their teeth, etc., or riding an exercise bike for a stress test. However, for emergent patients lying down on a gurney it shouldn't matter.

Undressing the patient, removing the bra if necessary, prepping the skin, and making sure the ECG leads are not wrapped around the IV line or O2 line, making sure the patient is in a relaxed semi-Fowlers, not propping themselves up on their arms, not shivering, and not twittering with the leads, and 99% of the time you can get an excellent tracing.

Permalink Reply by Ken Roberts on February 26, 2009 at 9:49am

The reason I place the limb leads on the actual limbs versus the torso is so I can get the best picture of axis deviation or lack there of on your 12 lead. The most improtant of which would be extreme right axis deviation, AKA ventricular in origin or Vtach. A bifisicular block (two seperate blocks) is also very important to watch out for and should tip you off that you have a patient that could deteriorate quickly.

Permalink Reply by Tom Bouthillet on February 26, 2009 at 10:02am

Ken -

It's a rare VT that shows a right superior axis! Come to think of it, it's a rare ECG of any type that shows a right superior axis. Last one I saw was severe hyperkalemia (bordering on a sine-wave configuration). Usually VT shows a right, left, or normal axis.

I certainly agree with you that syncope or chest patient patients with bifascicular blocks should be monitored carefully.

If you can't place the limb leads on the limbs (or won't) then familiarize yourself with the modified Mason-Likar limb lead placement so you're consistent!

Tom

Permalink Reply by ctboyer on February 26, 2009 at 10:38am

Tom,
I would have to respectfully diasgree with (or just add to) your comment on exrtreme right axis deviation (ERAD). While unusual and not as commen as marked right axis deviation, ERAD will be seen in the following conditions (but sorry Kenny, generally not VTAC!)

RVH
Anterolateral wall MI
WPW syndrome
and PE

Remember, PE mimics an MI, and will present as an S1, Q3, inverted T's in 1,2,3

Also, on the topic here, the leads are meant to be placed on the limbs (thats why they are called the limb leads). The large 12-Lead's used in most ED's even more so than the LP12's ect that we use in the field. While placing the limb leads on the chest may be more convienent, you may miss some ECG changes.

Permalink Reply by mark on February 26, 2009 at 11:01am

I was trained to do EKG's in 1977 by a Physicians Assistant who ran the Department of Cardiology and supervised Paramedic students at what is now known as Johns Hopkins Bayview hospital in Baltimore. Cardiology was his "Bag" as he put it. He stressed the importance of correct lead placement. He proved to us how suttle differences could be missed by lead placement. His favorite remark was to say " If it doesent matter, why do the people who make the EKG machines tell you where to place the leads to get the best picture?"

Permalink Reply by Tom Bouthillet on February 26, 2009 at 11:06am

I've never seen a right superior axis due to RVH, high lateral MI, S1Q3T3, or WPW. I'm not saying it's impossible. I'm saying it's very rare, even for VT.

In the last 10 years, I've seen one instance of bifascicular block RBBB/LPFB with a right superior axis and one case of hyperkalemia.

In other words, I wouldn't depend on this sign to differentiate between VT and SVT with aberrancy. It's academic at best.

Tom

Permalink Reply by ctboyer on February 26, 2009 at 11:18am

I never said you can diagnose VT by ERAD, i actually commented that VT is not included in that list. All my post was meant to point out is that ERAD does exist, and if you see it the cause is probably one of the reasons that I listed.

Just one of the issues/limitations of posting on a website rather than a live conversation!

Permalink Reply by Tom Bouthillet on February 26, 2009 at 11:20am

I wasn't referring to you. On the other hand, a wide complex tachycardia with a right superior axis would certainly point toward VT. But then, I always presume wide complex tachycardia is VT until proven otherwise, so it wouldn't change much.

Permalink Reply by Tracey Baker on February 26, 2009 at 5:32pm

Limb leads ARE limb leads--------ARMS:

Deltoid placement (obviously lateral)

LEGS: Quad Midline OR Medial placement at midpoint tibial area on fleshy portion of leg
..............................................................................................................................................................
LA/LL--Many times people think Left Leg/Left Arm---it IS Left Lateral and Left Anterior (same with Right -- RL/RA)---However, those this mnemonic works--LIMB LEADS are LIMB leads and should NOT be confused with Lateral and Anterior leads!! Placement does vary!..Because LA.LL. RA and RL are pretty standard on leads make sure they are placed correctly for proper axis and less varied read! Left lateral is generally placed under V5 and V6 (in the middle of and below), with V1 and V2 AT NIPPLE LINE on each side of sternum....Right and left anterior are placed on said side just below clavicals..Right lateral is an imaginary v5 and v6 on opposite side..Placed as LL.


On the other hand, a wide complex tachycardia with a right superior axis would certainly point toward VT. But then, I always presume wide complex tachycardia is VT until proven otherwise, so it wouldn't change much.....Tom B said

Absolutely!!!

I was trained to do EKG's in 1977 by a Physicians Assistant who ran the Department of Cardiology and supervised Paramedic students at what is now known as Johns Hopkins Bayview hospital in Baltimore. Cardiology was his "Bag" as he put it. He stressed the importance of correct lead placement. He proved to us how suttle differences could be missed by lead placement. His favorite remark was to say " If it doesent matter, why do the people who make the EKG machines tell you where to place the leads to get the best picture?" by MARK

THIS IS 100% TRUE.

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